- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $52.72 / $90.76 / $115.76
| Facility | 26 | $52.72 | $90.76 | $115.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.63 / $303.82 / $417.51
| Professional | | $184.63 | $303.82 | $417.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.00 / $455.00 / $455.00
| Professional | | $455.00 | $455.00 | $455.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.25 / $438.96 / $491.64
| Professional | | $208.25 | $438.96 | $491.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.30 / $245.82 / $512.13
| Professional | | $189.30 | $245.82 | $512.13 |